How pharmacy can start to solve the inequity puzzle

Abstract

We’ve all heard the statistic: Approximately 90% of Americans live within 5 miles of a pharmacy. That fact backs up the important argument that pharmacists are the most accessible health care provider and should therefore receive patient care authorities that would benefit all stakeholders. Those points are perfectly accurate. But they represent only a slice of an incredibly complex issue—especially as it pertains to BIPOC (Black, Indigenous, and people of color) communities and other underserved populations who experience disproportionately poor health outcomes. To truly ensure all patients get the high-quality care they need, we must dig deeper and consider all the factors behind persistent health inequities. And chief among these, experts agree, is structural racism. Structural racism is at the root of health inequities. Alex C. Varkey, PharmD, MS, FAPhA, is a member of APhA's Board of Trustees (BoT) and director of pharmacy services at Houston Methodist Hospital. His position gives him perspective on how structural racism manifests in the health system setting. “I think structural or systemic racism shows up in a lot of different ways. It could start with location of facility and subsequent access to care,” Varkey said. “There's a lot to uncover there with regard to how and where health systems and hospital systems are built and how that affects the ability to effectively care for the entire population.” He cites racial disparities in COVID-19 vaccination rates as an example. The data show that Hispanic and African American patients are disproportionately affected by COVID-19, he said, and that can be a direct result of a lack of access to care from pharmacists or other health care professionals. “So many vaccination sites require patients to drive or find some form of travel to receive a vaccine,” Varkey said. That leaves out those patients who don’t own cars or live in areas without robust public transportation systems. Anne Y. Lin, PharmD, is immediate past president of the American Association of Colleges of Pharmacy, a dean and professor at Notre Dame of Maryland School of Pharmacy, and a member of the APhA Task Force on Structural Racism in Pharmacy. She echoes Varkey's sentiments. Yes, the statistic is that each person lives within 5 miles of a pharmacy. But there are still areas that are pharmacy deserts, just like there are areas that are designated as food deserts, she said. “Let's say I’m a patient and there is a pharmacy 5 miles away. Well, I can’t really walk 5 miles,” Lin said. “You're still relying on public transportation or some method of transportation to get you to where you need to go.” Then there are dismissive attitudes about institutions that are in underserved communities. Some institutions considered highly reputable might be fortunate to have a large percentage of managed-care patients—patients who are employed and receive insurance benefits from their employer, Varkey said. “[But] if you look at county health systems that are designed to care for underprivileged or underserved populations, just because of who might comprise the patient population, there could be a stigma about the quality of care in those types of hospitals, even when the quality of care might be the same or even better than private institutions with more positive public reputation.” Technological gaps can also suppress vaccination rates among underserved populations. “Vaccination sites often make you register online for appointments, which requires internet access,” Varkey said. Furthermore, limited hours of operation can make getting vaccinated difficult. “Vaccination sites operate generally within the normal working hours,” Lin said. “And so, if you're working a type of job where the hours are very different, unless your employer lets you go, you're not going to be able to get to that appointment.” This is especially significant “for people of color, because you have large segments of these populations that are in jobs where they may be on different shifts and can’t get to it.” “There are populations, for example, in the African American community, where you can see vaccine hesitancy because of a lack of trust,” Lin said, “and it's historical events, such as the Tuskegee incident, that led to this.” Frank North, PharmD, MPA, wears many hats. He is a consultant pharmacist, the owner of Frank North and Associates LLC, and an instructional assistant professor at Texas A&M University Health Science Center Irma Lerma Rangel College of Pharmacy. He's also president-elect of the National Pharmaceutical Association. “[Pharmacy has] to acknowledge the hurt and the experiences of Black people. We have to understand the journey of how we got to America,” North said. “We didn’t ask to come. We were brought here not as people but to do work—as animals or as chattel beasts.” It's an uncomfortable conversation, and North appreciates that pharmacy is increasingly engaging in that conversation. “Everybody has to be uncomfortable in that space because it's uncomfortable for me, as a Black person, for that to be my history.” Now is the time to get personal, he said. “To move forward beyond racism, we [as individuals and groups] must talk about the past, because everything that we’ve achieved as Black people came through legislation—through law.” The Tuskegee Syphilis Studies involved 400 impoverished Black men deceived into participating in a 40-year experiment that assessed the effects of untreated syphilis—even after penicillin became available. The “experiment” didn’t just hurt the Black men who were its subjects. Ten percent of them passed the disease on to their wives, and 19 of their children were born with it. The project only ended when whistleblowers raised the alarm in 1972. And the perpetrator of this medical atrocity was the federal government—specifically the U.S. Public Health Service. So, North said, when the federal government starts pushing a vaccine for a disease that disproportionately harms their community—for 400 years enslaved and treated as property, less than human—it evokes fear and skepticism. “Especially when you want them to receive something at no charge.” North notes that Tuskegee is far from the only incident where respected health care providers inflicted medical torture on Black bodies, especially those who were trafficked and forced to perform hard labor. Take James Marion Sims, who is considered the “father of gynecology” and whose name is still spoken in exam rooms today—the modern speculum is known as the Sims speculum. Though he had no gynecology training, Sims became interested in the repair of vaginal fistulas, a consequence of childbirth that—due to a lack of contraception—was relatively common. Fistulas had a tremendous deleterious impact on women's quality of life. In 1845, he began performing experimental fistula surgeries on four enslaved Black women's bodies, including one woman he “bought” expressly for that purpose. He did so without anesthesia, partially because he believed that Black people did not feel as much pain as white people (a belief that reams of academic research prove persists to this day). “They screamed and yelled out of discomfort,” North said. Restriction on enslaved persons’ writing and reading probably hindered the recognition of myriad other examples. “Storytelling was how people learned about history. This [is why medical abuse] has become an urban legend that's true.” There is also skepticism about vaccine manufacturers in the Black community. “Johnson & Johnson was sued because of issues with their talcum powder,” North said. “People raised their eyebrows because months after that, [FDA and Johnson & Johnson] wanted them to trust their ‘life-saving’ vaccine. Then the pause in that vaccine due to blood clot concerns hurt the conversation.” Undocumented Americans may also be hesitant to get the COVID-19 vaccine—or health services in general—due to fear about what it could mean for themselves, their families, and their livelihoods. “An individual's immigration status can lead to an unwillingness to seek health care in general,” Lin said, “because they're afraid if it's discovered that they're undocumented, they could be deported.” Earlier this year, Notre Dame of Maryland partnered with the grocery chain Safeway to host a series of COVID-19 vaccine clinics. Together with local nonprofits, the organizers reached out to Latino/Hispanic communities to make sure they knew about the clinic and encourage them to make appointments. This was a common concern. Pharmacists can’t overcome hesitancy by treating apprehension as irrational. Pharmacists “need to be understanding and empathetic when individuals voice these concerns, and then develop a relationship” with them where you can provide accurate information. There's also a lot of misinformation out there, she said. Though it may be tempting to respond to hesitant patients by saying, “Those abuses happened a long time ago, I didn’t have anything to do with that, don’t blame me,” that's counterproductive. She's no longer a frontline pharmacist, but Lin herself recently established such a relationship on the job. It happened just as the pharmacy program was starting mass vaccine clinics on campus. “I work [from the university] and I’m generally there pretty late, so I see the housekeeping staff who clean the offices,” she said. “I struck up a conversation with one individual, and I knew I wanted to broach the subject of vaccines.” Lin asked the woman, whose mother was also a member of the housekeeping staff, about her thoughts on the COVID-19 vaccine and whether she was considering getting one. She wasn’t so sure. “Misinformation was part of her hesitancy.” “I simply acknowledged that there's lots of information and shared the accurate information with her. That took a couple of conversations,” Lin said. “Then I told her we were going to have clinics on campus, so that would certainly make it a lot easier to get.” The woman confirmed that she’d received the link to register, and Lin encouraged her to sign up. “I’d explained the reasons why it was important to [get the COVID-19 vaccine], but what I didn’t do was dismiss her concerns.” Both the woman and her mother ended up getting the vaccine at the campus clinic. The woman later thanked Lin for the information and making sure she knew how to get an appointment. “So, that's an example of how you need to build that trust and that conversation with individuals,” she said. No one on Earth is free from implicit bias. But since implicit bias has a significant effect on patient care, it's a problem pharmacy must attack. “A good example is pain management. When individuals come into the emergency room, sometimes health care providers make assumptions about certain populations,” Lin said. “Those assumptions impact decisions on how they treat [a patient's] pain in certain populations, which can result in treatment that is not as effective.” Assumptions may include how different people tolerate pain—just like the beliefs of medical abuser James Marion Sims, who used that claim to justify involuntary experiments on Black women. Studies have shown that Black children with appendicitis receive less analgesia for moderate pain and are one-fifth less likely to receive opioids for severe pain than white children; and that one-third of surveyed white medical students believed that Black skin is thicker than white skin and therefore less sensitive to pain. Other evidence exists that Black pain is undertreated and delegitimized. Sadly, there is more than enough evidence to prove that people have a harder time empathizing with someone unlike themselves, even though it's often unconscious and involuntary. This is so pervasive that health care providers—scientists—may unconsciously believe that a patient of another race is biologically and emotionally different from them. “The first step is to recognize it, but it isn’t just about awareness. You can’t just recognize that you make these assumptions and then go about your business as usual,” Lin said. “You must consciously think about that and make sure to check yourself as [you make clinical decisions] and raise those questions when you're working on a team.” Fighting implicit bias requires proactively questioning yourself and using that lens to evaluate your actions. “That's the only way that's going to change,” Lin said. “We must understand the presence of implicit bias within ourselves, acknowledge it, and accept the fact that it exists before we can really do anything else.” In the case of pain management, “the questions you need to ask yourself arewhether you have made any assumptions about, one, whether there's a high risk for abuse potential in this individual simply because of the population that they are in,” Lin said, “and two, how they respond to pain management. Are those real, or are they assumptions?” CDC formally declared racism to be a public health crisis in April 2021, and in late 2020, the American Heart Association (AHA) urged the health care system to acknowledge the nation's history of structural racism as a driver of health problems and shortened lives for BIPOC individuals. It's all about the social determinants of health (SDOH). Healthy People 2030 defines SDOH as the “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality of life outcomes and risks.” “The consequences of racism in the past persist in such a way that certain racial and ethnic groups still live in poor neighborhoods that have less green space, that have poor air quality, have a more dangerous environment that may preclude exercise and healthy behaviors, may have less nutritious food options, and certainly suboptimal educational experiences,” AHA President Mitchell Elkind, MD, said in a statement. “These things have not gone away.” Drilling down further, in a 2020 article published in the Journal of the American Pharmacists Association (JAPhA), Arya and colleagues echoed AHA's assessment. “Systemic racism is a public health emergency and a root cause of [SDOH],” the article reads. “A deeper understanding of systemic racism is needed to address health disparities and [SDOH] in an effective and sustainable way.” The Robert Wood Johnson Foundation's County Health Rankings Model identified clinical care as only 20% of the factors that affect health outcomes. More significant were physical environment and social and economic issues, which constitute half of the factors affecting outcomes. “In addition, these, along with clinical care factors such as access to care and quality of care, eventually have an impact on the health behaviors and outcomes of our patients,” the JAPhA paper stated. Assessing SDOH facilitates patient-centered care that relies on the full picture of individuals’ lives, from address to family dynamics to culture and beyond. The explicit association of SDOH on health and of structural racism on SDOH is key to more equitable care. Despite that, pharmacists must be cognizant of assumptions based on a patient's SDOH. The JAPhA authors note that training on diversity and cultural competency are part of a pharmacy education, and that “has resulted in students and health professionals linking cultural diversity to negative outcomes and experiences without addressing the root cause.” “We teach this in school and we teach students some generalities about particular cultures or groups, but [pharmacists] should really use that information as a hypothesis,” Lin said. “If you're just applying those generalities to all people of that culture or that group, well, that's the same thing as stereotyping. You have no idea whether, for example, a patient is a third-generation individual, or they are new immigrant. Little [assumptions] like that can make individuals feel unwelcome.” Thinking about structural racism and the ways we may unknowingly perpetuate it isn’t easy. Lin hopes her pharmacist colleagues understand that the process is not about blame but acknowledging an issue and addressing it. “We have to remember what we committed ourselves to with the Oath of a Pharmacist and not allow these other things to interfere with that responsibility,” she said. “These are really difficult topics.” Doing the work, not just on the personal level but on institutional levels, is crucial to the success of the pharmacy profession, Houston Methodist's Varkey said. “The story of how we're finally recognized as providers starts with the question, ‘How can I ensure that all patients, regardless of race, ethnicity, gender identity, any other category you want to use—that they have all received the care they need in order to survive and thrive?’” he said. “And it starts with taking account of why it is that specific individuals from certain underserved populations aren’t receiving the best care and what can we do to advocate for the structural changes that will prevent it in the future.” A son leads pharmacy organizations that once excluded his father The only pharmacy program in his home state of Virginia didn’t want Leonard L. Edloe: The Medical College of Virginia, later Virginia Commonwealth University (VCU), denied admission to Black students. Unable—unwilling—to let him earn his degree there, the school instead paid for Edloe to get his education elsewhere. The policy was quintessential structural racism, a system that provides one race with advantages it denies to another. But it didn’t stifle Edloe, PharmD, ThM. From injustice emerged his long and distinguished pharmacy career. He landed at Howard University College of Pharmacy in Washington, DC. Howard is a highly prestigious historically Black university that counts U.S. Vice President Kamala Harris, Nobel Prize–winner Toni Morrison, and Supreme Court Justice Thurgood Marshall among its alumni. Edloe is grateful for his Howard education, the high caliber of his professors, and the intellectual and personal relationships with his fellow students. “I actually learned Black history just walking around the campus,” he said. “I didn’t know about a Frederick Douglass. I didn’t know about a Charles Drew, who discovered blood plasma.” Drew's son was even a classmate of Edloe's and his daughter a good friend. Unlike most pharmacy schools at the time, Howard also had many students who were women—one of whom became his wife. “I would’ve had a narrow view of the profession, a narrow view of life, if I’d stayed in Virginia,” he said. Howard's Washington, DC, location provided other rewards. Edloe mystified his pharmacy peers because although he could rarely be found at the university's library, he was always prepared for class with his assignments complete. What they didn’t know was that Edloe had found an ideal study spot at APhA's national headquarters, which boasted a library that was bigger than Howard's and introduced him to several influential figures. His relationships with APhA staff and leadership led him to become the first member of the House of Delegates review committee and eventually, a national student leader, a member of the APhA BoT and president of the APhA Foundation board. Today he's a member of the APhA Task Force on Structural Racism in Pharmacy. But Edloe's most significant influence was his own father, himself a pharmacist and owner of a Virginia pharmacy. Leonard L. Edloe, Sr. was active in the profession, but unlike his son, APhA wasn’t part of his life. Why? Because as a Black man, he was ineligible to be a member. To join APhA, one had to be a member of a state association—and Virginia's would not admit Black pharmacists. Rejected and excluded, Edloe's father became an incorporator of the National Pharmaceutical Association (NPhA). “He always told me, from the first day I got my license, ‘You have to be better. You have to prove you are better,’” Edloe said. Though Edloe's experience with APhA was very different, his father's pain never fully faded; Edloe, Sr. declined to attend the APhA annual meeting where his son was inducted as a national officer (his mother did attend). He was certainly proud of his son, and it was a consolation that Edloe decided to work alongside him at the family's pharmacy after he finished his education. Edloe, Sr. died just 2 years later. If he were alive today, he’d be bittersweet about another of his son's accomplishments—Edloe was recently elected president-elect of the Virginia Pharmacists Association (VPhA). In 2022, he'll become the first Black president of the very institution that treated his father as inferior and undeserving. That legacy hasn’t been entirely exorcised, however. He's held many high-profile APhA volunteer leadership positions and was elected to its BoT in the 1980s, but that doesn’t mean his relationship with APhA is uncomplicated. After the end of his BoT term, Edloe stepped back from active involvement to join the nonprofit world and became a pastor—that is, until a peer nominated him for one of APhA's professional awards. At the time, BoT minutes were shared with former trustees, including Edloe. In one set, he read that the board had decided to reopen the award nomination period “to get somebody of more quality to be the recipient of the award.” Apparently, they didn’t feel Edloe met their standards. The award went to a friend who he respected and loved, but Edloe dropped his membership because of what he read in the minutes. “I was out of APhA for at least 12 years because that was insensitive, and it was like I really didn’t matter.” Edloe now talks to pharmacists of color to encourage them to join or pursue volunteer leadership with APhA, and many feel just like he did those decades ago—that they aren’t needed or wanted. “That's why [the APhA Task Force on Structural Racism] is so important,” he said. “Those people need to know that they matter, and [that] they're needed and wanted in association work.” Edloe recalls many instances where racism affected his professional life. As a student, he worked at a chain pharmacy. “And I will never forget this—this guy came in and called me the n-word and refused to let me fill his prescription. The manager came up and said, ‘If he doesn’t fill your prescription, nobody ever will.’” Racism also invaded his personal life. After Edloe and his wife graduated from Howard, they moved to Richmond, VA, so he could work at his father's small pharmacy. “I can’t tell you how little he paid me, so, naturally, he couldn’t pay her,” he said. But because his wife had previously worked at a national chain, she figured she could get a job at one of the locations in the area. “The guy [at the chain pharmacy] told her he didn’t know how his customers or the district manager would feel about a colored person filling their prescriptions,” Edloe said. She ended up taking a job 3 hours away, in Roanoke. “She was actually farther from home than if she’d stayed in DC.” Edloe believes the separation and the resentment that came with his wife's long commute took a toll on the marriage. The couple eventually split up. Because of her tough experience, his wife convinced their daughter not to pursue a pharmacy career. With no one to pass it on to, he sold Edloe's Professional Pharmacies, the pharmacy that had once been his father's, after 40 years as its proprietor. “So, I wonder what could have been if that [racist incident] hadn’t happened.” Even a pharmacy benefit manager (PBM) audit had specious motivations, Edloe believes. “I was a Black man with a successful practice, but some people wanted to portray that as untrue.” Edloe's pharmacy served many patients with HIV/AIDS. “Their prescriptions were off the chain, as far as price was concerned,” he said. One PBM sent an auditor who “came in with this list to audit me with. There were 100 prescriptions and 60 of them were HIV/AIDS drugs that cost $2,000 or more. They were trying to catch me on something, maybe an extra rebill or something. I could’ve possibly owed them $200,000, that's how ridiculous this audit was,” Edloe said. Each time Edloe pulled out a prescription, he’d ask the auditor, “Why is this [justified] if you can see there's nothing nefarious in it?” The auditor offered a weak excuse, but Edloe wasn’t having it. “I said, ‘Audit's over. This has to be explained.’ So he left.” He seldom thought about the incident until a church in Richmond invited him to preach about the struggles that Black men face. After the service, he saw his wife talking to a woman who had been in the audience, but the woman walked away when she saw Edloe coming. His wife told him in the car that the woman had approached her to plead for absolution. “She asked if we would forgive her being part of [a plot] to shut me down,” he said. The woman had worked for that PBM and knew that the audit was an attempt to cast Edloe as a cheat: Her employer simply couldn’t conceive of a Black pharmacy owner who had succeeded because he was smart, savvy, and skilled. This time in history is ripe for real action on structural racism, Edloe said. “It's so fertile now because, as a nation, we're at such a delicate point.” The January 6, 2021, insurrection at the U.S. Capitol building was a prime example. “When I turned on the TV and watched it, I actually shook, it upset me so much.” Edloe believes that if people don’t stand up for what's right, wrong will overtake our lives as we know them. “All of us lose [if that happens], because there's so much richness in our diversity,” he said. “But do we take advantage of it? Do we use it to make each other better? Or will everyone just hoard for themselves?” Many obstacles to equity are all about power. There are people at the top who have power they refuse to share. And then there are other people who don’t have real power, but for whom privilege has created the illusion of power, he said. “It's frightening to them when they pick up the paper and read that the nation's going to be a Brown nation,” he said. “It's a pivotal time because [those people] can either accept it and try to work together and improve everybody's lives, or [they] can go down the dark road so [they] can keep this perceived power.” It's important to Edloe to keep sharing the history of oppression across the globe and what it can teach us about what's happening in our country today. “We're doing a tutorial program at the church where I’m a pastor, and the students are so far behind that it hurts,” he said. One young man did a project about the Holocaust that focused on individuals who’d been sent to Auschwitz. “I asked him if he understood the context of what happened, and he didn’t,” Edloe said. “We sat down and had a long conversation about how Germany had been defeated [in World War I] and was having economic problems, and how [the Nazis] used Jews as a scapegoat.” He's still learning, too. “I’m learning the Native American story. And I never knew what the Asians have gone through, that for a long time even their children who were born here were not allowed to be citizens,” he said. “It really did something to me to sit there and look at that and seeing them being lynched, burned in their homes, and their communities destroyed for no reason. Angel Island in San Francisco admitted only 10% of arrivals into the country, and we're dealing with that same thing right now with the border.” These are things both the young and old must understand if we're to build a better future, Edloe said. A conversation with APhA task force member Adrienne SimmonsAdrienne Simmons, PharmD, MS, BCPS, AAHIVP, is director of programs at the National Viral Hepatitis Roundtable and a member of the APhA Task Force on Structural Racism in Pharmacy. She recently sat down with Pharmacy Today for a conversation about her work on the task force, how racism affects patients with hepatitis, and what she’d like pharmacists to know about caring for these patients.Why do you serve on the APhA structural racism task force, what does the work mean to you, and what do you hope the task force will achieve?By serving on the task force, I’m able to use my privilege and voice to increase the chances that all patients and pharmacists can lead healthy lives.This work means treating structural racism as the public health crisis that it is, which requires vulnerability, introspection, resources, and action.I hope the task force brings awareness to and develops a consciousness around racism as a social determinant of health, and that we encourage our profession to stand up against any and all injustices.Your work centers on viral hepatitis. How does structural racism play into that work? How could dismantling structural racism improve care for patients with viral hepatitis or at risk for developing viral hepatitis?Structural racism is the root cause of the stark inequities that exist among communities of color living with viral hepatitis. We have a cure for hepatitis C (HCV), yet Black Americans and Native Americans have higher HCV-related morbidity and mortality compared to white Americans.Additionally, Asian Americans account for 58% of Americans living with hepatitis B, while only accounting for 6% of the population. If we eliminated all other barriers—such as stigma, lack of insurance, and language barriers—inequities would persist among communities of color. Only by dismantling racism can we eliminate barriers to people getting educated, tested, or vaccinated for viral hepatitis.How does implicit bias affect viral hepatitis care and prevention? What are some things pharmacists might not know about their patients or should make sure to talk to their patients about?Assumptions are frequently made about whether patients living with hepatitis are deserving of treatment or able to adhere to treatment based on their race, drug use, housing stability, and incarceration history.Implicit bias ultimately perpetuates stigma, worsens health outcomes,